PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY / PROCEDURE
Policy/Procedure Number: MCUP3130
Policy/Procedure Title: Osteopathic Manipulation Therapy
Original Date: 06/17/2015
Effective Date: 10/01/2015
Lead Department: Health Services
☒External Policy
☐ Internal Policy
Next Review Date: 06/17/2016
Last Review Date: 06/17/2015
Applies to:
☒ Medi-Cal
☐ Healthy Kids
☐ Employees
Reviewing
Entities:
☒ IQI
☐P&T
☒ QUAC
☐ OPERATIONS
☐ EXECUTIVE
☐ COMPLIANCE
☐ DEPARTMENT
☐ BOARD
☐ COMPLIANCE
☐ FINANCE
☒ PAC
Approving
Entities:
☐ CEO
☐ COO
☐ CREDENTIALING
Approval Signature: Robert Moore, MD, MPH
☐ DEPT. DIRECTOR/OFFICER
Approval Date: 06/17/2015
Effective Date: 10/01/2015
I.
RELATED POLICIES:
A. N/A
II.
IMPACTED DEPTS:
A. Health Services,
B. Member Services
C. Claims
III.
DEFINITIONS:
A. Osteopathic medicine is a branch of the medical profession in the United States, whose physicians are
known as Doctors of Osteopathy (DO).
B. Osteopathic physicians are trained in Osteopathic Manipulative Treatment (OMT), also known as
Osteopathic Manipulative Medicine (OMM), a core set of manual manipulative techniques used to treat
somatic dysfunction.
IV.
ATTACHMENTS:
A. N/A
V.
PURPOSE:
Partnership HealthPlan’s Board approved an enhanced coverage benefit to cover OMT services on April 22,
2015. This policy defines the services that are covered under this benefit.
VI.
POLICY / PROCEDURE:
Osteopathic Manipulation Therapy (OMT) Coverage
A. OMT services should only be provided by physicians skilled, trained and experienced in providing these
services. This includes Doctors of Osteopathic Medicine, but may include other licensed health care
providers who complete supplementary training in this area.
B. Only credentialed PCPs will be paid for OMT services under this enhanced benefit.
C. No treatment authorization is required to perform OMT, if it is performed by a primary care clinician
credentialed with PHC.
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Policy/Procedure Number: MCUP3130
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 06/17/2016
Last Review Date: 06/17/2015
☐ Healthy Kids
☐ Employees
Policy/Procedure Title: Osteopathic Manipulation Therapy
Original Date: 06/17/2015
Effective Date: 10/01/2015
Applies to: ☒ Medi-Cal
D. Codes covered. The following CPT® codes are covered under this OMT policy:
1. 98925 Osteopathic manipulative treatment (OMT); 1-2 body regions involved
2. 98926 Osteopathic manipulative treatment (OMT); three to four body regions involved
3. 98927 Osteopathic manipulative treatment (OMT); five to six body regions involved
4. 98928 Osteopathic manipulative treatment (OMT); seven to eight body regions involved
5. 98929 Osteopathic manipulative treatment (OMT); nine to ten body regions involved
E. OMT is a proven medical therapeutic option for treatment of musculoskeletal disorders, including acute
and chronic lower back pain.
F. OMT is unproven and not medically necessary for treatment of:
1. The patient’s condition has returned to the pre-symptom state.
2. Little or no improvement is demonstrated within 30 days of the initial visit despite modification of
the treatment plan.
3. Concurrent chiropractic manipulative therapy, for the same or similar condition, provided by another
health professional whether or not the healthcare professional is in the same professional discipline.
4. Manipulative therapy under anesthesia.
5. Mon-musculoskeletal disorders (e.g. asthma, otitis media, infantile colic, etc.)
6. Prevention/maintenance/custodial care
7. Internal organ disorders (e.g., gallbladder, spleen, intestinal, kidney, heart or lung disorders)
8. Temporomandibular Joint (TMJ) Disorder
9. Scoliosis correction
10. Craniosacral therapy (cranial manipulation)
11. Manipulative services that utilize nonstandard techniques such as applied kinesiology technique,
network and neural organizational technique
G. All OMT services conducted should be documented in the medical record, including the diagnosis, any
disability that is present, the treatment used, the length of the treatment, and the effectiveness of the
treatment.
VII.
REFERENCES:
A. Spinal Manipulative therapy for chronic low-back pain. Cochrane abstract. January 31, 2013
B. Spinal Manipulative therapy for acute low-back pain. Cochrane abstract. December 12, 2012
VIII.
DISTRIBUTION:
A. Provider Manual
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services
X.
REVISION DATES:
PREVIOUSLY APPLIED TO:
*********************************
In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with
involvement from actively practicing health care providers and meets these provisions:
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Policy/Procedure Number: MCUP3130
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 06/17/2016
Last Review Date: 06/17/2015
☐ Healthy Kids
☐ Employees
Policy/Procedure Title: Osteopathic Manipulation Therapy
Original Date: 06/17/2015
Effective Date: 10/01/2015
Applies to: ☒ Medi-Cal



Consistent with sound clinical principles and processes
Evaluated and updated at least annually
If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be
disclosed to the provider and/or enrollee upon request
The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar
illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits
covered under PHC.
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